The patient was a 23 day old Saudi girl who was born to a 41 years old lady at 35 weeks of gestation via cesarean sections due to fetal distress. Maternal history revealed the mother was gravida 5 para 6 with no known chronic medical illness. She started her follow up in the private sector in which first ultrasound showed a single viable fetus but unfortunately an anomaly scan was not done. She was taking supplement medication during pregnancy once she tested positive on a pregnancy test as used to take folic acid, iron and calcium with no good compliance on taking them at times. There was no history of gestational diabetes or pregnancy induced hypertension as she was screened during pregnancy follow-up. No history of radiation exposure. Her previous 4 pregnancy concluded with first normal vigainal delivery and at 2nd was cesarean section due to abruption placenta and 3rd was cesarean section of twins delivery and the fourth was cesarean section due to previous cesarean section. However, all children were full term and in good condition with no chronic medical illness. In regards to family history, the parents are not consanguineous. There is one maternal aunt with trisomy 21. At the delivery room, the APGAR score was 5 and 7 at 1 and 5 minutes respectively. She was admitted to NICU due to respiratory distress which started on CPAP initially then required intubation on the 4th day of life. On the 5th day of life she was transferred to our hospital due to limited other service and financial issues. Upon admission to our hospital, her physical examination revealed a newborn girl under radiant-warmer and intubated with connection to mechanical ventilations. Her vital signs were within acceptable values and she was pinkish skin color and not pale, jaundiced, or cyanosed. Her growth parameters based on age and sex were in the 10th percentile for weight, length, and head circumference. She had dysmorphic facial features including widely separated eyes, downward slanting of the palpebral fissure, microphthalmia, retrognathia, and low seat ears. She had area of loss of scalp skin and skull bone with seen brain tissue and sagittal sinus were exposed that was measure 6*5 cm in size as shown in Figure 3. Additionally, she had a clenched fist and overlapping fingers and rocker bottom feet. Lung auscultation revealed vesicular breathing with equal air entry bilaterally and no added sounds. Precordium auscultation revealed medium pitched high grade continuous murmur heard best at the pulmonary position with a harsh machinelike quality that often radiated to the left clavicle. She had a soft and lax abdomen without tenderness or hepatosplenomegaly. Laboratory investigations at the age of 5 days included complete blood count (CBC) which revealed a hemoglobin of 12.1 g/dl, haematocrit of 35.8 %, MCV of 113 fL, MCH of 38.2 pg, MCHC of 33.9 g/dl, RDW of 16.9 %, platelet of 121 k/ul, WBC of 23.6 k/ul in which neutrophils were 74 % lymphocyte of 11% and monocyte of 15 %. Patient blood group is O positive and the direct coombs test (DCT) was negative. Liver function test showed total bilirubin of 13.7 mg/dl, direct bilirubin of 1.1 mg/dl, SGOT of 75 U/L, SGPT of 14 U/L, lactate dehydrogenase (LDH) of 889 U/L, GGTP of 118 U/L, total protein 4.1 g/dl and albumin of 2.7 g/dl. Renal function test showed a BUN of 13 mg/d, creatinine of 0.82 mg/dl, sodium of 138 mEq/L, potassium of 3.5 mEq/L, CO2 of 18 mEq/L, Cl 103mEq/L, anion gap 17. C-reactive protein level was less than 0.1 mg/dL. Virology screens including Toxoplasma IgG and IgM was negative, Rubella IgG was positive and IgM was negative, Cytomegalovirus (CMV) Antibody IgG was positive and IgM was negative, Herpes Simplex Virus IgG was positive and IgM was negative, Hepatitis B surface antigen and antibody were non reactive and core antibody was negative. Blood culture did not show bacterial growth. On the 9th day of life, a chromosomal analysis showed a female karyotype with three copies of chromosome number 13 in all 20 metaphase cells counts. Radiology investigations include head magnetic resonance imaging (MRI) revealed absence of scalp and calvarium at the parietal region with no herniation is visualized as shown in Figure 4. The patient was managed with moist gauze dressing, topical antibiotics ointment, and povidone-iodine. A multidisciplinary team meeting was held that involved neurosurgeon, neonatologist, and pediatric genetics consultants who agreed on do not resuscitate (DNR) with no further surgical intervention as survival rate of trisomy 13 is poor along with associated skull bone defect.